RSSAuthor Archive for Steve MacArthur

Steve MacArthur

Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at

He ain’t HVA, he’s my opportunity

An interesting topic came across my desk relative to a January 2013 survey, and it pertains to the use of your HVA process as a means of driving staff education initiatives.

During the Emergency Management interview session during this particular survey, the surveyor wanted to know about the organization’s hazard vulnerability analysis (HVA) process and how it worked. So, that’s pretty normal—there are lots of ways to administer the HVA process—I prefer the consensus route, but that’s me.

But then the follow-up question was “How do you use the HVA to educate staff and their actions to take?” Now, when I first looked at that, I was thinking that the HVA process is designed more as a means of prioritizing response activities, resource allocations, and communications to local, regional, and other emergency response agencies, etc., but staff education? Not really sure about that…

But the more I considered the more I thought to myself, if you’re going to look at vulnerability as a true function of preparedness, then you would have to include the education of staff to their roles and responsibilities during an emergency as a critical metric in evaluating that level of preparedness. The HVA not only should tell you where you are now, but also give you a sense of where you need to take things to make improvements and from those improvements, presumably there will be some element of staff education. A question I like to ask of folks is: “What is the emergency that you are most likely to experience for which you are least prepared?” Improvement does not usually reside in things you already do well/frequently. It’s generally the stuff that you don’t get to practice as often that can be problematic during real-life events. One example is the management of volunteer practitioners—this can be a fairly involved process. But if you haven’t practiced it during an exercise, there may be complexities that will get in the way of being able to appropriately respond during the emergency. Which is why I recommend if you haven’t practiced running a couple of folks through the volunteer process, what better time than during an exercise?

Finders and fixers: Can we get them to say something if they see something?

One of things that continuously comes up on my pondering list is how to enlist the eyes, ears, noses, and fingers of frontline staff in the pursuit of the early identification of risks in the physical environment. Unless one of the facilities maintenance folks happens to be in the right place at the right time, in all likelihood, an aberrant condition is going to manifest itself to somebody working out at the point of care/point of service. And my firm belief is that the organizations that manage environmental risks most effectively (including the “risks” associated with unannounced regulatory survey visits) are the organizations that have most effectively harnessed these hundreds, if not thousands, of agents in the field 24/7.

So, my latest take on this is that we can subdivide the totality of every (and, really, any) organization into two main constituencies—finders and fixers. The key is to get the finders mobilized, so the fixers (who, truth be told, in most organizers are currently finder-fixers) can focus on actually repairing/replacing stuff. I’m at a loss to explain why this can be such a difficult undertaking, so I’ll ask you, dear reader: What do you think? Or if you’ve found a way to really mobilize the “finders” in your organization, how did you make it happen? Did you have to guilt them into it, did you establish a “bounty” system for reporting conditions, etc.? I am firmly convinced that if we can enlist these folks in the identification of hazards, we can really move towards a process for ensuring constant readiness.

Excellence amid chaos: A word from the land of the bean and the cod

If I might beg your indulgence, I just wanted to take a moment to recognize the herculean efforts of the Boston hospital community during last week’s bombing at the Boston Marathon. All too often, when disaster strikes, hospitals don’t receive many kudos—I guess the expectation is that hospitals are always ready for the worst (true, that).

Over the last decade or so as a consultant, I have had the opportunity to work with many of the folks who were charged with coordinating response and, to be honest, the level and nature of response from the hospitals in Boston was no great surprise to me. While Marathon Monday is certainly a “big” date on the preparedness calendar for Boston hospitals, I’ve seen a lot of the work behind the scenes and can only be impressed by the commitment to preparedness on the part of so many.

But in saying that, I also recognize that, by and large (or at least the ones I’ve visited), I believe that hospitals in the United States are extraordinarily well-prepared to handle emergencies of virtually every stripe. That’s not to say that every response effort is absolutely perfect—but these folks learn from those “opportunities” and continue to improve their organizations’ ability to respond to emergencies.

I hope to have the opportunity to work with more of you folks in the future, but in closing, please join me in a tip of the cap to the hospital folks in Boston. I am extremely proud to have worked with some of you and proud of the efforts by all concerned!

Postscript: I penned the above prior to the successful law enforcement resolution to the bombing in Boston. It sounds like it’s going to be a while before we find out anything of use regarding the planning, etc., of this catastrophic event, but I think it’s certainly worth tipping the cap once again to the awesomely coordinated efforts of all levels of the law enforcement community.  I’m sure there will be ample Monday-morning quarterbacking relative to just about any decision/strategy involved in bringing this incident to a (sort of) close, but all I know is that it was a sizable measure of comfort when flying back home to Boston last Friday evening to know that the matter was in hand and Boston had resumed some semblance of normalcy. It was good to be home!

Between the sheets…the Safety Data Sheets!

Every once in a while I like to take questions from the studio audience and today I’d like to address the question of where one has to have copies of their Safety Data Sheets (in the interest of history, I’m going to resist using the “old” term Material Safety Data Sheets) in each department.

So, the short answer is “no,” there is no specific requirement to have copies of the SDS in each department. But there is some contextual stuff that requires a bit of diligence, so I think a quick review of the language in the Hazard Communications Standard may be useful (the section of the Standard dealing with SDS is 1910.1200(g) – we’re just looking at the portion that discusses how employers are expected to manage them):

1910.1200(g)(8)  The employer shall maintain in the workplace copies of the required safety data sheets for each hazardous chemical, and shall ensure that they are readily accessible during each work shift to employees when they are in their work area(s). (Electronic access and other alternatives to maintaining paper copies of the safety data sheets are permitted as long as no barriers to immediate employee access in each workplace are created by such options.)

1910.1200(g)(9) Where employees must travel between workplaces during a workshift, i.e., their work is carried out at more than one geographical location, the material safety data sheets may be kept at the primary workplace facility. In this situation, the employer shall ensure that employees can immediately obtain the required information in an emergency.

1910.1200(g)(10) Safety data sheets may be kept in any form, including operating procedures, and may be designed to cover groups of hazardous chemicals in a work area where it may be more appropriate to address the hazards of a process rather than individual hazardous chemicals. However, the employer shall ensure that in all cases the required information is provided for each hazardous chemical, and is readily accessible during each work shift to employees when they are in their work area(s).

So, basically it all really boils down to that last statement. You need to have SDS information for each hazardous chemical and that information has to be readily accessible to employees when they are in their work area(s). As I think we’ve discussed in the past (but if we haven’t, we’re going to, starting now), the Hazard Communication Standard is a performance standard (much like many of the Joint Commission standards). The HazComm Standard does not specify much in the way of compliance strategies, but rather focuses on establishing certain expectations and then each organization has to figure out how to meet those expectations from an operational standpoint. You can go about this pretty much any way that you want—as long as you can effectively provide access to SDS information for employees. If you can effectively provide access without having copies of SDS at the department level, then that’s what you can do. And if you can’t, then you have to come up with a strategy that does—which for the department-level access means copies of the SDS in the department.  And to keep things on a front and center kind of standing, I might suggest that the effectiveness of the process for providing access to SDS information would make a very good performance measure upon which to evaluate the effectiveness of your Hazardous Materials and Waste Management program. Test the process—see if folks can retrieve the information they need without too much difficulty. If it’s a web-based program, ask them to show you how they work the process. Fax on demand? Same thing—have staff show you the process works. That way you “know” that you have an effective process.

How does your escort service measure up? Hope you’re not letting things get too hot…

I know we’ve (at least sort of) talked about this before (for those of you who might need some thought refreshment in that count or if you’re new to the conversation, see this previous post), but there are still some findings being generated during Joint Commission surveys this year, so I figured it might be worthwhile revisiting one aspect of the whole nuclear medicine security issue.

Let me preface things by noting that I don’t believe that there have been too many instances (a number that approaches zero) in which nuclear medicine deliveries to hospitals have been diverted or otherwise redirected for nefarious purposes. That said, there are certain provisions in the regulations regarding radiation safety and controls programs in healthcare that require couriers delivering nuclear materials to your hot lab (presuming you have one) to be escorted when they are in the hot lab. Unfortunately, if you are interested in finding out what the deal might be for you, the first point to keep in mind is that some states (a handful or so) administer their radiation control programs in accordance with the Nuclear Regulatory Commission (NRC) statutes which do require the escort into the hot lab. But (and isn’t there always a “but”?), there are a great many other states that have an “agreement” with the NRC that allows them to pretty much make their own way (to see where your state figures into the equation, this would be a good place to start) in this regard.

Now the good survey folks from our friends at TJC know about the requirement for escorting the couriers, but they are not necessarily conversant with the requirements for the agreement states—and some of the agreement states do not specifically require the escorting of the couriers into the hot lab. So you need to know (yes, another in the long list of things you need to “know”) what the requirements are in your state, so if it does come up in survey (and it is coming up with increasing frequency), you will know where you stand from a compliance standpoint. As a further thought on this coming up as a survey finding, I suspect that you would need to be prepared to show the surveyor(s) the regulatory evidence that you don’t have to do the escort thing, and, if that is not sufficient evidence in the moment (and we’ll discuss how that might happen in a moment), then you will probably need to make full use of the post-survey clarification process.

Now, the reason I suspect that the state regs might not be enough revolves around the general concept of best practices, etc., which are becoming increasingly similar to actual regulations (or so it seems—it might just be my overactive imagination. I think not, but I’m prepared to admit that there is a possibility). To that end, I suggest (and if you’ve been paying any attention over the years I’ve been scribbling this blog, you probably have a good idea where I’m going now—and I certainly wouldn’t want to disappoint) that you conduct a (ta-da!) risk assessment to demonstrate that the levels of security in place are of sufficient robust-ity (I know that’s not a real word, but shouldn’t it oughta be?) that an unescorted courier results in minimal, if any, risk to your organization.

As I look back at this little screed, I’m glad that I did not promise (or otherwise imply) that I was going to be brief. At any rate, make sure you understand the security requirements in your state and make sure that you are poised and ready to educate any surveyors (real or imagined) that might push on your process.

One thing leads to another

An interesting development on the survey front this year; it may be merely a blip on the compliance radar screen (I know of two instances in which this happened for sure—but if you folks know of more, please share), but if this signals a sea change in how The Joint Commission is administering surveys, you’d best have your ducks in a row.

So, I’ve heard tell of two instances in which the survey team arrived at an organization with the results of the previous triennial survey clutched in their paws, with the intent being to validate that the actions submitted as part of the Evidence of Standards Compliance (ESC) process did indeed remedy the cited deficiency. Now I think we can agree that the degree to which we can fix something and keep it fixed over the course of 36 or so months can be a bit of a, how shall we say, crap shoot. As we’ve noted in one fashion or another, lo these many years, fixing is easy—keeping it fixed is way difficult.

And so dear friends, those of you in the survey bucket for 2013 should dig out those survey results from last time, review the ESC submittal and make sure that what was accepted by TJC as a means of demonstrating compliance with the standards is indeed the condition/practice that is in place now. And the reason this is so very, very important, just to complete the thought, is that there is a pesky little standard in the APR chapter of your beloved Accreditation Manual  (APR stands for Accreditation Participation Requirements, and the standard in question is APR.01.02.01) that requires “(t)he hospital provides accurate information throughout the accreditation process.” So if a surveyor gets to thinking that there may have been some less than forthcoming aspect of your action plans, etc., you could be looking at a Preliminary Denial of Accreditation, a most unpleasant state of affairs, I assure you. So let’s give those “old” findings at least one more ride around the track and make sure that we’ve dotted all the “i’s” and crossed all the “t’s.”

Don’t know why there’s no sun up in the sky…stormy weather!

In case you’ve not heard (I don’t see as much info on the various list servs I monitor when it comes to the timing of the unannounced survey process), there have been some instances this year when unannounced Joint Commission surveys have been occurring months earlier than anticipated (nobody has gone outside of their official “window,” which opens 18 months prior to the anniversary date of your last triennial survey).

Certainly during 2012, there were some folks who went six weeks or so early, but we’re talking four or five months early. There was some indication that the incredibly reliable nasty weather in the Midwest and Northeast over the last little while has resulted in some schedule juggling by the folks in Chicago (and doing as much traveling as I do, I can well understand the impact of stinky weather). As has become an increasingly familiar mantra, you can’t predict future survey activities/results based on past experiences, but I figured it might be worth sharing the possibility. You all are supremely prepared for your survey I’m sure, but I figured I’d share that bit of info.

One other survey process wrinkle of some note is the tale of an organization that was anticipating a five-day onsite survey and ended up having a four-day survey—with additional surveyors on the team to compress the five days of activities into four days. So, for those of you with five-day surveys who have blocked off Mondays in hopes of maybe blocking out the entire week, there may be a little surprise in store. This has only happened once that I know of, but if anyone out there has a story to share on that front, I’m sure we would all be very interested to hear.

At any rate, as I type this, I am looking out at a very gray day at the airport in Chicago with a forecast of snow. I guess we’re not quite a week into spring, so this must just be a period of transition. Hopefully we transition pretty darn quickly. I do wonder “where those birdies is” (with apologies to Mr. Nash)…

Documentary evidence: More you need to know…

Another perpetually sticky wicket in the survey process (and we’ve discussed this, oh, once or twice before) is the timeliness of documentation from maintenance and testing vendors and the expectations of how that process has to be managed. During an ASHE-sponsored webinar last fall, George Mills posited the scenario in which there is a delay (delay times can vary, but you probably have a pretty good idea of how long you have to wait for reports to come back from your vendors) in receiving a report for fire alarm testing in which a handful of devices failed during routine testing. If you don’t receive the failure information immediately upon its identification by the vendor, what you are saying, in effect, is that it’s okay for me not to “know” (there’s that word again) how reliable my fire alarm system is for a month while I’m waiting for the report. If any of you think that it is indeed “okay” not to know might want to think about another line of work. From an empirical standpoint, a failed fire alarm device puts the building occupants (patients, staff—you know, those folks) at a greater risk, which is never, never, never a good idea. And what if you don’t get the report for six weeks, the failed devices haven’t been replaced, and now you’re looking at the possibility for having to manage the deficiency with a PFI, ILSM assessment—the whole magillah. Truthfully, you have better things to do with your time.

Mr. Mills’ suggestion (and I think it’s a good one, having made the suggestion at least once or twice in the past) is to ensure (either contractually or otherwise) that any deficiencies identified are in your possession before they “complete” their work. You can set it up so they let you know at the end of each testing day (that would be my preference) or at the end of the engagement. But you have got to have that information in your possession as soon as it can be made available to you. The occupants of your building depend on each and every element of your systems—fire alarm, fire extinguishment, medical gas and vacuum, emergency power—you know that list by heart and it’s your responsibility that they are managed appropriately.

I’m fixing a hole

For our next topic of conversation regarding George Mills’ address to the folks in ASHE last year, we take up the ever-vexing task of managing penetrations. Now, there’s certainly been a lot of ire pointed towards the folks who run cabling in healthcare—IT, cabling contractors, etc. But this represents something of a sea change in the public face of this problem—while there certainly any number of “perps” when it comes to making holes in rated barriers, there is a very clear sense that appropriate management of the process results in the buck stopping at a single destination: the desk of the facilities management professional.

So, a quick show of hands: How many folks are using an above the ceiling work permitting process? That many? That’s a pretty good number. But how are you administering that process? Have you told the entire organization about the process? Maybe established a bounty for finding folks working in the ceiling without a permit? You have tens of thousands, if not hundreds of thousands, of square feet in which mischief can occur above the ceiling. If you establish the condition that anyone (and that means  folks employed by the hospital—everyone is equal in the eyes of a penetrated rated barrier) working above ceiling must display a permit on the ladder or lift—and get folks to call in when someone is working without a permit, then you can start to manage the process. By the way, I’m a great believer in rewarding folks who drop a dime for this and don’t be cheap; at least buy ’em lunch somewhere nice. And if you find you’re spending too much money feeding your dime-droppers, then that means that your permit process is not working very effectively!

When you find someone working above the ceiling without a permit, throw the bum out! Nothing draws attention to a process like a good swift kick in the pocketbook. If someone does not want to work by our rules, then they can work elsewhere, pure and simple. Then they can explain to their boss why they couldn’t finish a job, as opposed to you having to explain to your boss why you’re getting an RFI for rated barrier penetrations. I know which scenario I’d prefer…

One last thought: As for “existing” penetrations, Mr. Mills clearly indicated the expectation that facilities will undertake an above-the-ceiling inspection at least once per year to catch any deficiencies that were not captured by the normal process. Then you either fix them properly or manage them as a PFI (with applicable ILSM assessment—please don’t forget that piece of the puzzle). It’s really just that simple.

Suites for the sweet

Continuing our coverage of George Mills’ address to the ASHE folks last fall, we turn to what was described as an area with a “lot of problems”:  The management of suites.

So, before we get started on this one, I’d like you to make a mental list of all the areas in your organization that have been designated as suites (if you’re not sure what a “suite” is, please e-mail me on the side at the address listed below and I will try to help you to get acquainted with this most useful of life safety concepts). Now that you have that mental list appropriately populated, take out your life safety drawings and check to see how many of those suites are specifically identified (this means the perimeter boundaries of the suite, as well as the square footage of the suite). If you have suites that you have mentally designated, but haven’t gone through the process of having them identified on your life safety drawings, in all likelihood you are looking at RFIs for anything from corridor storage to non-latching corridor doors (suites can have stuff and patient rooms doors that don’t latch – benefit!).

In some ways, this very much comes under the category of things that you have to “know”; it is not nearly enough to “think” that something is compliant. If you expect to successfully navigate the survey process, you have to translate the “think” to the “know.” As a facilities management professional, it is incumbent upon you to have absolute knowledge of where your facility “lies” on the compliance chart. By all means, use your vendors and service folks to gain that knowledge, but be assured of one thing: They won’t be the ones in the “hot seat” come survey time—and you’d better know how to cool off that seat.